HF comorbidities — viva

Stem

Practice viva. The examiner describes an older patient with chronic HFrEF who is tired, breathless, losing weight and low in mood, with diabetes and kidney disease, and works through the comorbidities that change HF care.^[1]

Branch A — Which comorbidities do you screen for?

Examiner: What do you check for at diagnosis, and why?^[1]

Strong answer:

• ESC 2026 recommends, in suspected HF, a full blood count, kidney function (eGFR and UACR), electrolytes, liver function, thyroid function, HbA1c, lipids and iron status (TSAT and ferritin) when screening for comorbidities (Class I, Level C).^[1]
• Its key messages say patients should be routinely screened and treated for non-cardiovascular comorbidities (such as diabetes, CKD, obesity, iron deficiency, anxiety and depression) and for frailty.^[1]
• AHA/ACC/HFSA 2022 says over 85% of patients with HF have two or more additional chronic conditions.^[2]

Branch B — Iron deficiency

Examiner: How do you define iron deficiency in HF, and is the definition changing?^[1]

Strong answer:

• The previous definition is ferritin <100 ng/mL, or ferritin 100–299 ng/mL with TSAT <20%; it was used in almost all recent intravenous iron trials.^[1]
• ESC 2026 says it does not reliably identify absolute or functional iron deficiency, and that ferritin is highly sensitive to inflammation and oxidative stress.^[1]
• TSAT <20% has been proposed as an alternative definition, mainly based on explorative analyses and meta-analyses of RCTs; it has higher sensitivity and specificity, is associated with higher mortality independently of phenotype, and the Task Force supports it while calling for new trials.^[1]

Follow-up: What are the treatment rows?^[1]

• ESC 2026: intravenous iron is recommended in symptomatic HFrEF with iron deficiency to alleviate symptoms and improve QoL (Class I, Level B1), and should be considered to reduce the risk of HF hospitalisation (Class IIa, Level B1).^[1]
• The ESC 2026 Task Force says evidence on strong endpoints is not conclusive, and the ESC text adds that patients with TSAT <20% might benefit most.^[1]
• AHA/ACC/HFSA 2022: in HFrEF and iron deficiency with or without anaemia, intravenous iron replacement is reasonable to improve functional status and QoL (COR 2a, LOE B-R); intravenous repletion of iron has been shown to improve exercise capacity and QoL, but IRONOUT HF showed no such improvement with oral iron supplementation.^[2]
• ESC 2026 HFrEF means LVEF <50%, whereas AHA/ACC/HFSA 2022 HFrEF means LVEF ≤40%.^[1][2]

Branch C — Anaemia

Examiner: Her haemoglobin is low but iron studies are normal. Would you give erythropoietin?^[1]

Strong answer:

• Not for anaemia related to HF. ESC 2026 says erythropoietin-stimulating agents should be avoided for anaemia related to HF: in RED-HF, in HFrEF with mild to moderate anaemia, darbepoetin alfa failed to reduce all-cause death or HF hospitalisation and showed an increased risk of thromboembolic events.^[1]
• AHA/ACC/HFSA 2022 says they should not be used to improve morbidity and mortality in HF with anaemia (COR 3: Harm, LOE B-R).^[2]
• NHFA/CSANZ 2018 says erythropoietin should not be used routinely for anaemia in HF because of an increased risk of thromboembolic adverse events (strong recommendation against; moderate quality of evidence), and that referral to a haematologist or renal physician to consider erythropoiesis-stimulating agents may be considered in patients with CKD (practice advice); with her kidney disease, that referral may be considered.^[5]
• Look for reversible causes first: iron deficiency is the most common cause, but vitamin B12 and folate deficiency and CKD can contribute (NHFA/CSANZ 2018).^[5]

Branch D — Diabetes, kidneys and potassium

Examiner: How does diabetes change her HF drugs, and what if her creatinine rises?^[1]

Strong answer:

• ESC 2026 says HF treatment is the same with or without T2DM, and SGLT2 inhibitors are recommended in all patients with HF and T2DM, independently of HbA1c (text; no class or level given).^[1]
• Saxagliptin and thiazolidinediones have been associated with an approximately 30% increased risk of HF hospitalisation and are contraindicated in HF (ESC 2026).^[1]
• After starting ACE-I/ARNI/ARB, MRA or SGLT2 inhibitor, a transient decrease in kidney function should not prompt interruption, and a creatinine rise of <50% above baseline is considered acceptable as long as eGFR remains >15 mL/min/1.73 m² (ESC 2026).^[1]

Follow-up: Her potassium is 5.7 mmol/L on spironolactone. Do you use a binder?^[1]

• ESC 2026 makes no specific recommendation on potassium binders because evidence of clinical benefit is insufficient, and REALIZE-K showed a signal towards more HF deterioration with sodium zirconium cyclosilicate, although it was not powered for clinical outcomes.^[1]
• AHA/ACC/HFSA 2022 calls their effectiveness to improve outcomes by facilitating continuation of RAASi therapy uncertain in HF with potassium ≥5.5 mEq/L on a RAASi (COR 2b, LOE B-R).^[2]
• If she has CKD with HFrEF and eGFR >30 mL/min/1.73 m², the 2026 CKM guideline says novel oral potassium binders may be reasonable to reduce risk of hyperkalaemia and allow RAAS inhibition (COR 2b, LOE B-R).^[3]

Branch E — Sleep-disordered breathing

Examiner: She snores and stops breathing at night. What next?^[1]

Strong answer:

• ESC 2026 says suspected sleep-disordered breathing should be referred for overnight polysomnography to diagnose it and document whether central or obstructive apnoea predominates.^[1]
• Adaptive servo-ventilation is not recommended in HFrEF with predominant central sleep apnoea because of an increased risk of CV and all-cause death (Class III, Level A), based on SERVE-HF.^[1]
• With predominant obstructive sleep apnoea it may be considered to improve sleep quality, health-related QoL and symptoms (Class IIb, Level C); ADVENT-HF was neutral on its primary outcome but improved those measures.^[1]

Branch F — Weight loss, frailty and mood

Examiner: She has lost weight and seems frail and low. How do you approach this?^[1]

Strong answer:

• ESC 2026 supplementary Table S17 says cachexia can be defined as weight loss >7.5% in the absence of oedema, with a 50% 18-month mortality vs 17% in non-cachectic HF patients.^[1]
• Assessment of anxiety, depression and frailty should be considered in HF to support personalised care plans and to identify factors that may contribute to adverse outcomes (ESC 2026 HF guideline, Class IIa, Level C); the ESC 2026 cardiac rehabilitation guideline recommends psychological screening (depression, anxiety) for comprehensive risk assessment in patients with heart disease to guide appropriate referral, intervention and management (Class I, Level C).^[1][6]
• The same cardiac rehabilitation table recommends psychological interventions for patients with CAD and HF to improve mental functioning (reduce anxiety and depressive symptoms) and HRQoL (Class I, Level B1).^[6]
• It recommends cognitive behaviour therapy for patients with CAD, HF or an implanted ICD to improve mental functioning (depression, anxiety, HRQoL) and reduce cardiovascular risk (Class I, Level B1).^[6]
• Telemonitoring and computer or cell phone-based psychosocial education and training should be considered in CAD and HF to reduce anxiety and depression symptoms (Class IIa, Level B1).^[6]
• For depression, tricyclic antidepressants should be avoided; sertraline and escitalopram were safe but did not significantly reduce depression versus placebo (ESC 2026).^[1]

Branch G — Atrial fibrillation

Examiner: She develops AF. Give me two HF-specific rows.^[1]

Strong answer:

• ESC 2026: beta-blockers are recommended in stable HFrEF with AF as first-line therapy for short- and long-term rate control (Class I, Level C).^[1]
• ESC 2026: DOACs are recommended in preference to VKAs in HF to prevent stroke and thromboembolism, except with moderate or severe mitral stenosis or mechanical prosthetic valves (Class I, Level B1).^[1]
• ACC/AHA/ACCP/HRS 2023: in AF with known LVEF <40%, nondihydropyridine calcium channel blockers should not be given because they may exacerbate HF (COR 3: Harm, LOE B-R).^[4]